Chapter 2: Report Topics

The topics addressed by the EPCs reflect areas of significant demand for information by partner organizations and their stakeholders.  Topics may include the prevention, diagnosis, treatment and/or comparative effectiveness of particular clinical and behavioral conditions; use of alternative or complementary therapies; and appropriate use of commonly provided services, procedures, or technologies.  Topics also may include issues related to the organization and financing of care, such as risk adjustment methodologies, market performance measures, provider payment mechanisms, and insurance purchasing tools, as well as measurement or evaluation of provider integration of new scientific findings regarding health care and delivery innovations. Topics of evidence reports published to date are listed at  http://www.ahrq.gov/clinic/epcix.htm#clinicalcat.

Return to Contents

Nominating a Topic

AHRQ encourages both non-federal partners (i.e., professional societies, health systems, employers, insurers, providers and consumer groups) and federal partners (e.g., the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the Social Security Administration) to nominate topics. 

AHRQ is very interested in receiving topic nominations from professional societies and organizations representing members of minority populations, nominations on topics that have significant impact on AHRQ priority populations, and nominations on topics covering 14 priority conditions established for the Comparative effectiveness program that have been identified through a process involving wide input from public and Federal agencies. AHRQ's priority populations include the following:

• Low-income groups
• Minority groups
• Women
• Children
• Elderly individuals
• Individuals with special health care needs, such as those with disabilities or those who need chronic care or end-of-life health care or who live in inner-city and rural areas 

The 14 priority conditions identified for 2009 are:

1. Arthritis and nontraumatic joint disorders
2. Cancer
3. Cardiovascular disease, including stroke and hypertension
4. Dementia, including Alzheimer's disease
5. Depression and other mental health disorders
6. Developmental delays, attention-deficit hyperactivity disorder, and autism
7. Diabetes mellitus
8. Functional limitations and disability
9. Infectious diseases including HIV/AIDS
10. Obesity
11. Peptic ulcer disease and dyspepsia
12. Pregnancy including preterm birth
13. Pulmonary disease/asthma
14. Substance abuse

Nominations of topics for AHRQ evidence reports should focus on specific aspects of prevention, diagnosis, treatment and/or management of a particular condition; an individual procedure, treatment or technology; or a specific health care organizational or financial strategy.  Special consideration is given to topics having a significant impact on the health status of priority populations and priority conditions. 

Return to Contents

Selection Factors for Nominated Topics

In selecting topics for assignment to EPCs, AHRQ will consider the extent to which a nominated topic addresses the following factors:

1. Burden of disease, including severity, incidence and/or prevalence or relevance of organizational/financial topic to the general population and/or AHRQ's priority populations, which include:
   • Low-income groups, minority groups, women, children, the elderly and individuals with special health care needs, such as those with disabilities or who need chronic care or end-of-life health care or live in inner-city and rural areas.
2. Controversy or uncertainty about the topic and availability of scientific data to support the systematic review and analysis of the topic.
3. Total costs associated with a condition, procedure, treatment,technology, or organizational/financial topic, whether due to the number of people needing care, the unit cost of care or indirect costs.
4. Potential impact for reducing clinically significant variations in the prevention, diagnosis, treatment or management of a disease or condition, or in the use of a procedure or technology.
5. Potential for informing and for improving patient and/or provider decisionmaking; improving health outcomes; and/or reducing costs.
6. Relevance to the needs of the Medicare, Medicaid, or other Federal health care programs.
7. For topic nominations from previous partners, AHRQ also will consider partner efforts in translation and dissemination of products derived from EPC evidence reports, as well as successes in use and impact of these products.

Nominations of topics may be submitted on an ongoing basis.  AHRQ does not reply to individual nominations, but considers all nominations during the selection process.

How to Select a Nomination

For each topic, the nominating organization must complete and submit online the required form available at: http://effectivehealthcare.ahrq.gov/getInvolved.cfm?involvetype=sr.

The form is designed to help AHRQ understand the topic the nominating organization is interested in, the populations to whom it applies, what benefits or harms are of greatest interest,  and what health care services should be assessed and compared. 

Return to Contents

Guidance on Framing Evidence Questions for AHRQ Topic Nominations

Topic nominations should include approximately three to five specific, well-defined questions that are appropriate for evidence reports. An appropriate question is one that can be addressed by an EPC by a review of the available evidence. As described below, questions that ask about clinical judgment or appropriate care for certain patients are not suitable for EPC review. However,  an EPC evidence report may present an evidence base from which another group, such as the nominating partner organization, can derive a practice guideline or policy that would address such questions.

Questions that are vague or otherwise inappropriate for evidence reports can lead to unrealistic expectations among AHRQ, the EPCs, and the nominating partners as well as unnecessary delays. This section presents common problems with topic questions and provides examples of evidence questions that are appropriate for EPC evidence reports.

Problem Questions on Clinical Topics

Question #1:  What are the appropriate indications for [procedure X]?

This type of question is not appropriate for an evidence review because its answer would be:

"The appropriate indications for [procedure X] are a, b and c."

Such an answer entails moving beyond reviewing evidence to state a judgment regarding the clinical circumstances under which the procedure should be performed. Doing so would require developing a clinical practice guideline.  Although a partner organization may intend to develop a practice guideline based on the EPC evidence report, it is not the role of EPCs to develop such guidelines.  The following examples show how a question of this nature could be transformed into a question that is suitable for an EPC evidence review:

• Inappropriate: What are the appropriate indications for arthroscopic surgery?
• Appropriate: Does arthroscopic surgery improve [certain outcomes] for [certain types of] patients?
• Appropriate: For what types of patients is there strong evidence that arthroscopic surgery improves [certain outcomes]?

• Inappropriate: Should procedure X] be routine in childbirth?  If not, what are the indications for the procedure?
• Appropriate: What is the strength of the evidence for routine versus restricted use of [procedure X] in childbirth?  What is the evidence that [procedure X] improves [certain outcomes] for [particular clinical circumstances of] childbirth?

Question #2:  Can [procedure X] be used to treat [general disease Y]?

Questions that ask, "Can/should this be used?" are too vague; they do not reveal the evidence question of interest to a potential partner.  It is unclear whether the potential partner is asking if it is possible for the procedure to be used or if it is appropriate for it to be used, or whether the partner is asking about the nature of the evidence that such use is effective.

• Inappropriate: Can the [laboratory test Y] be used as a screening test for hypertension?
• Appropriate: How effective is the [laboratory test Y] as a screening test for hypertension?

Question #3:  What is the role of [procedure Z] in the treatment of pressure ulcers?

This type of question is too vague to be addressed through an evidence review.  It does not suggest whether any particular indications, populations, care settings, or outcomes are of interest to the partner.  It does not specify whether evidence of effectiveness, safety, cost-effectiveness, or other outcome or impact are of interest.  This type of question could be transformed into an evidence question as follows:

• Inappropriate: What is the role of [procedure Z] as a stand-alone therapy and as an adjunct to conventional therapy for pressure ulcers?
• Appropriate: In which patient populations does [procedure Z] as stand-alone therapy improve healing of pressure ulcers?  In which patient population does [procedure Z] as an adjunct to conventional therapy improve healing of pressure ulcers?

The following is an example of a topic with accompanying questions that are well-defined and can be answered by an evidence review:

Topic: Uterine Artery Embolization (UAE) for Treatment of Fibroids™

Questions:

1. What are the health risks and benefits of UAE in relation to other surgeries (e.g., hysterectomy, myomectomy)?
2. What are the effects of UAE on future fertility and pregnancy-related outcomes?
3. What are the complications associated with UAE?

Problem Questions on Organization, Financing, and Delivery Topics

Question #1:  What are the effects on health care of [financing mechanism X]?

This question is vaguely worded.  It is unclear what aspect of health care is of interest to the potential Partner. 

• Inappropriate: What are the effects on health care of defined contribution models?
• Appropriate: How does utilization of previously covered health care services change when employers offer defined contribution models to their employees?

Question #2: Should [patient type X] be treated in [practice setting Y]?

Answering this question entails moving beyond reviewing evidence to state a judgment regarding the practice setting in which the patient should be treated. 

• Inappropriate: Should patients with severe mental illness be placed in community-based care or treated in inpatient settings?
• Appropriate: What is the evidence that placing patients with severe mental illness in community-based care yields same or better access, effectiveness [on certain outcomes], and costs compared to placement in inpatient treatment settings?

Question #3: Is [provider type P] superior to [provider type Q] in providing [a certain type of care]?

This question does not provide a basis for determining relative performance.  Further, what constitutes "superior" may be subject to judgments of value, not just evidence. 

• Inappropriate: Do high-volume hospitals provide superior cardiac care?
• Appropriate: Are physicians practicing at academic medical centers or hospitals designated as "centers of excellence" for cardiac care more likely than other acute care hospitals to provide beta-blockers to patients who have had heart attacks?

Developing a Causal Pathway or Analytic Framework

A "causal pathway" or "analytical framework" is a useful means of specifying evidence questions for many topics.  These graphic displays depict direct and indirect linkages between interventions and outcomes.  They can be particularly useful for topics involving a chain of events or decisions, each of which could be the subject of an evidence question.  Examples are screening or diagnostic interventions, which may affect health outcomes indirectly, i.e., via the use of treatments indicated by the results of a screening or diagnostic test.  Although typically used to present clinical problems, they can be used as well for organizational, financing and other types of interventions or programs in health care.  Graphing a topic of interest can help a prospective partner formulate evidence questions of interest.  A sample causal pathway is shown in Figure 1.

Figure 1: A General Causal Pathway—Screening Procedure and Alternative Treatments

Source:  Adapted from Harris 2001.

The literature on evidence-based health care provides other guidance that may be useful in formulating questions for the EPC program.  For example, specific, well-defined clinical questions can be formed using the approach shown in Figure 1.

Additional resources with guidance on formulating clinical questions that can be addressed by evidence reviews follow:

• Sackett DL, et al. Evidence-based Medicine: How to Practice and Teach EBM. London: Churchill Livingstone; 2000:2.
• Richardson WS, Wilson MC, Nishikawa J, Hayward RSA. The well-built clinical question: a key to evidence-based decisions. ACP J Club 1995;123:A12–3.
• U.K. Centre for Evidence-Based Medicine: http://www.cebm.net/focus_quest.asp

Figure 2: Formulating an Evidence Question

Type of Question	Tips for Building Question	Example
Patient Population or Problem	"How would I describe this group of patients?" Balance precision with brevity.	"In patients with heart failure from dilated cardiomyopathy who are in sinus rhythm..."
Intervention (a cause, prognostic factor, treatment, etc.)	"Which main intervention is of interest?" Be specific.	"...would adding anticoagulation with warfarin to standard heart failure therapy..."
Comparison Intervention (if necessary)	"What is the main alternative to compare with the intervention?" Be specific.	"...when compared with standard therapy alone..."
Outcomes	"What do I hope the intervention will accomplish?" "What could this exposure really affect?" Be specific.	"...lead to lower mortality or morbidity from thromboembolism? Is this enough to be worth the increased risk of bleeding?"

Source:  Adapted from Centre for Evidence-Based Medicine, University Department of Psychiatry, Warneford Hospital, Headington, Oxford, UK.

Return to Contents
Proceed to Next Section